Research in Otolaryngology 2017, 6(6): 81-87 DOI: 10.5923/j.otolaryn.20170606.02 Quality of Life in Patients with Nasal Obstruction after One Year of Septoplasty Abdullah Alotaibi Department of Otolaryngology Head and Neck Surgery, College of Medicine, Hail University, Saudi Arabia Abstract Background: Nasal blockage is a frequent cause of increased nasal airway resistance, which has negative impact in the quality of life. Therefore, the aim of this study was to assess the quality of life in patients with nasal obstruction after one year of Methodology: This study included a series of patients presented with nasal obstruction and subsequently undergone Several nasal obstruction clinical complains were evaluated included: nasal congestion, nasal blockage, breathing trouble, sleeping trouble, and exercise problem. Results: The majority of patients attended with nasal blockage followed by breathing trouble, sleeping trouble, nasal congestion, exercise problem, and other complications, representing 123(94%), 114(87%), 110(84%), 109(83.2%), 93(71%) and 5(3.8%), respectively. Conclusion: Septoplasty leads to a highly significant enhancement in quality of life and relief of symptoms. Keywords Septoplasty, Nasal blockage, Breathing trouble, Nasal congestion, Sleeping trouble 1. Introduction Nose is a mean for evaluating the disease-specific quality of life associated with nasal obstruction. Nasal obstruction is a public complaint in several population settings. Deviated nasal septum (DNS) might cause nasal obstruction and negative impact on the quality of life of individuals [1]. When caused by a DNS, septoplasty is the method of choice for the treatment these patients [2]. Nasal blockage or inadequate air flow via the nose, can impact significantly on the person's quality of Life. The prevalence nasal obstruction greatly vary [3]. There are many factors incriminated as causes for nasal obstruction, include: rhinitis, adenoid hypertrophy, turbinate hypertrophy and sinonasal polyps. DNS is a very mutual cause of nasal obstruction, of simple diagnosis and eventual treatment is based on DNS have a prevalence ranging from 19 to 65 % due to diverse criteria for describing a deviated septum [4, 5]. Septoplasty is the third most common surgery [6] done in the ear nose and throat (ENT) specialty and can be performed under local or general anesthesia, and the procedures might be very challenging for some surgeons. A precise preoperative diagnosis is important for the success of surgery. Intraoperative imagining through microscope or endoscope is very supportive for the surgeon. The current method of septoplasty with the stages of approach, mobilization, resection/repositioning and reconstruction/fixation is * Corresponding author: abdullahdak.md@gmail.com (Abdullah Alotaibi) Published online at http://journal.sapub.org/otolaryn Copyright 2017 Scientific & Academic Publishing. All Rights Reserved offered. As pathologies of the caudal septum are responsible for failures of septal surgery, some special problems of this region such as the vertical fracture of the caudal septum, the lack of caudal septum or anterior convexities of the cartilaginous septum are debated [7]. Septoplasty as is one of the most common operations done in otolaryngology, usually anterior nasal packing is done regularly to avoid postoperative bleeding, septal hematoma or nasal synechia. At present, transseptal sutures have gained a bigger practice area, not only for preventing the complications such as septal hematoma and bleeding but also closing any accidental tears of septal mucosa and bringing extra support for the cartilage pieces reserved in septoplasty [8]. Complications related to submucous septal resection or septoplasty may create improper sign and diagnosis due to incorrect or partial analysis and interpretation of the anatomical structures of the nose and nasal function tests. Complications can rise from methodological failures throughout the techniques of septal surgery from the incision to the reconstruction of the septum. Early and late complications can be caused by infections in the postoperative period encompassing only the mid-facial region or the entire body. Postoperative and late complications may also arise from damage to the septal soft and hard tissues [9]. Our perception on health and health care is fluctuating. Substantial factors in this modification are insights on the social magnitudes of diseases and the knowledge that medical interventions may lengthen life and improve quality of life [10, 11]. Thus the consequence analysis is one of the essential means for the evaluation of quality of medical care.
82 Abdullah Alotaibi: Quality of Life in Patients with Nasal Obstruction after One Year of Septoplasty Therefore, the aim of this study was to assess Quality of life in patients with nasal obstruction after one year of 2. Materials and Methods This study included a series of patients presented with nasal obstruction and subsequently undergone Archives related to all patients selected for septoplasty between 2012 and 2017 were retrieved from ear, nose, throat (ENT) department, King Khalid hospital in Hail, Northern Saudi Arabia. Only adults over 18 years of age were included in the study. Patients medical records were investigated, and patients with a history of rhinoplasty, cranial and facial trauma or bone deformity (except DNS), and patients with a mass in the nasal cavity were excluded from the study. Only patients with apparent nasal obstruction related clinical presentation (complains) were considered. Several nasal obstruction clinical presentations were recorded included: nasal congestion, nasal blockage, breathing trouble, sleeping trouble, and exercise problems. Demographical characteristics including; age, gender and residence were also recorded. The different initial clinical presentations and complications were compared after three one year of Ethical consent Our study protocol was conformed according to the 2013 Declaration of Helsinki and this study was approved by ethics committee of College of Medicine, University of Hail, Saudi Arabia. Statistical analysis Statistical analysis was performed using SPSS software for Windows (version 16.0, SPSS Inc., Chicago, IL, USA). Categorical variables are given as frequencies and percentages, and continuous variables. For all statistical comparisons, a p value below 0.05 was considered statistically significant. 3. Results This study investigated patients presented with different clinical complains related to nasal obstruction. Out of the 131 patients, 112(85.5%) were diagnosed with DNS and the remaining 19 (15.5%) patients were diagnosed with other nasal obstructive disorders. The majority of patients attended with nasal blockage followed by breathing trouble, sleeping trouble, nasal congestion, exercise problem, and other complains, representing 123(94%), 114(87%), 110(84%), 109(83.2%), 93(71%) and 5(3.8%), respectively. Table 1 summarizes the distribution of the patients by nasal obstruction related clinical complications before septoplasty and after one year of For nasal congestion, symptoms completely disappeared from 67/109(61.5%) patients. Severe and moderate symptoms present only in 2/62(3.2%) and 8/30 (26.7%) respectively, as indicated in Table 1, Fig 1. These findings indicated that septoplasty is important for the management of nasal congestion and this was found to be statistically significant P <0.0001. For nasal blockage, symptoms were completely wiped out from 87/123(70.7%) of the patients. Severe and moderate symptoms persist only in 4/82(4.9%) and 7/26 (27%) respectively, as indicated in Table 1, Fig 1. These findings indicated that septoplasty is a must for the treatment of nasal blockage and this was found to be statistically significant P <0.0001. For breathing trouble, symptoms completely disappeared from 80/114(7) of the patients. Severe and moderate symptoms disappeared from 1/70(1.4%) and 6/27 (22.2%) respectively, as indicated in Table 1, Fig 1. These findings indicated that septoplasty is necessity for the treatment of breathing trouble and this was found to be statistically significant P <0.0001. Table 1. Distribution of the study population by nasal blockage related clinical complains before septoplasty and after one year of septoplasty Variable Nasal Congestion Nasal Blockage Category Breathing Trouble Sleeping Trouble Exercise Problem Before septoplasty After 1 year septoplasty P value Mild 17 32 <0.0001 Moderate 30 8 Severe 62 2 None 0 67 Total 109 109 Mild 15 25 <0.0001 Moderate 26 7 Severe 82 4 None 0 87 Total 123 123 Mild 17 27 <0.0001 Moderate 27 6 Severe 70 1 None 0 80 114 114 Mild 20 12 <0.0001 Moderate 20 5 Severe 70 6 None 0 87 Total 110 110 Mild 31 11 <0.001 Moderate 28 1 Severe 34 0 None 0 81 Total 93 93
Research in Otolaryngology 2017, 6(6): 81-87 83 12 10 8 6 57% 2% 67% 3% 61% 1% 64% 6% 37% 4 2 62% 71% 7 69% 87% 5% None Mild Moderate Severe Figure 1. Description of patients by clinical symptoms at initial presentation and after one year of septoplasty For sleeping trouble, symptoms completely disappeared from 107/110(97.2%) of the patients. Severe and moderate symptoms disappeared from 3/70(4.3%) and 6/20 (3) respectively, as indicated in Table 1, Fig 1. These findings indicated that septoplasty is essential for the treatment of sleeping trouble and this was found to be statistically significant P <0.0001. For exercise problems, symptoms completely disappeared from 81/93(87%) patients. Severe and moderate symptoms disappeared from 0/34() and 1/28 (3.6%) respectively, as indicated in Table 1, Fig 1. These findings indicated that septoplasty is critically needed for the treatment of exercise problem and this was found to be statistically significant P <0.0001. Table 2 summarized the distribution of the study subjects by clinical presentation before septoplasty and after one year of septoplasty by gender. All initial clinical complications (including: nasal congestion, nasal blockage, breathing trouble, sleeping trouble and exercise problem) were significantly amended after one year of septoplasty (P <0.0001), both for males and females. However, within each gender group there was variations within the degree of symptoms, as shown in Fig 2&3. Other complications such as bleeding and loss of smell were completely disappeared. Additionally, about 57/131(44%) of the patients witnessed a change in the shape of their noses after one year of Table 3 summarised the distribution of the patients by age at initial presentation and after one year of The improvement after septoplasty was statistically significant in all age ranges (P < 0.0001). However, the improvement has varying changeability in different ages, as indicated in Fig 4. For nasal congestion, symptoms were completely resolved from 16/25(64%), 18/31(58%), 13/23(57%), 11/17(65%) and 9/13(69%) of the patients in age groups 20, 21-25, 26-30, 31-35, and 36 years, respectively. Table 2. Distribution of patients by clinical presentations and gender at initial presentation and after one year of septoplasty Variable Category Males Females Nasal Congestion Nasal Blockage Breathing Trouble Sleeping Trouble Exercise Trouble Before After Before After None 0 51 0 16 Mild 11 24 6 8 Moderate 23 5 7 3 Severe 48 2 14 0 Total 82 82 27 27 None 0 65 0 22 Mild 8 19 7 6 Moderate 19 6 7 1 Severe 66 3 16 1 Total 93 93 30 30 None 0 63 0 17 Mild 11 19 6 8 Moderate 22 5 5 1 Severe 55 1 15 0 Total 88 88 26 26 None 0 67 0 20 Mild 13 9 7 3 Moderate 15 3 5 2 Severe 56 5 14 1 Total 84 84 26 26 None 0 64 0 17 Mild 25 8 6 3 Moderate 20 1 8 0 Severe 28 0 6 0 Total 73 73 20 20
84 Abdullah Alotaibi: Quality of Life in Patients with Nasal Obstruction after One Year of Septoplasty 10 9 8 7 6 5 4 3 2 1 59% 62% 2% 71% 7 3% 63% 72% 1% 67% 8 6% 38% 88% None Mild Moderate Severe Figure 2. Description of males patients by clinical presentations and gender at initial presentation and after one year of septoplasty Table 3. Distribution of patients by clinical presentations and age at initial presentation and after one year of septoplasty Variable Category 20 years 21-25 26-30 31-35 36 Before After Before After Before After Before After Before After Nasal Congestion None 0 16 0 18 0 13 0 11 0 9 Mild 8 7 1 9 3 9 3 3 2 4 Moderate 5 2 14 4 3 1 4 1 4 0 Severe 12 0 16 0 17 0 10 2 7 0 Total 25 25 31 31 23 23 17 17 13 13 Nasal Blockage None 0 18 0 26 0 11 0 8 0 5 Mild 0 5 8 8 3 12 2 6 2 7 Moderate 9 1 8 4 4 2 3 1 2 1 Severe 16 1 24 2 20 2 13 3 9 0 Total 25 25 40 40 27 27 18 18 13 13 Breathing Trouble None 0 16 0 25 0 7 0 4 0 6 Mild 3 6 7 8 9 6 5 3 3 7 Moderate 6 0 6 3 3 0 4 3 5 0 Severe 13 0 24 1 1 0 1 0 6 1 Total 22 22 37 37 13 13 10 10 14 14 Sleeping Trouble None 0 19 0 24 0 18 0 14 0 12 Mild 3 2 9 4 2 4 4 0 2 2 Moderate 4 1 7 2 6 1 3 1 0 0 Severe 15 0 19 5 15 0 9 1 12 0 Total 22 22 35 35 23 23 16 16 14 14 Exercise Problem None 0 15 0 25 0 18 0 13 0 10 Mild 6 0 6 5 9 4 4 0 6 2 Moderate 5 0 12 1 6 0 4 0 1 0 Severe 4 0 13 0 7 0 5 0 5 0 Total 15 15 31 31 22 22 13 13 12 12
Research in Otolaryngology 2017, 6(6): 81-87 85 None Mild Moderate Severe 9 8 7 6 5 4 3 2 1 52% 59% 53% 73% 3% 58% 65% 54% 77% 4% 3 85% Figure 3. Description of females patients by clinical presentations and gender at initial presentation and after one year of septoplasty 12 10 8 6 4 2 72% 64% 65% 58% 57% 65% 41% 44% 69% 38% 20 years 21-25yrs 26-30yrs 31-35yrs 36 Breathing-trouble Sleeping-trouble Exercise-problem Nasal-congestion Nasal-blockage Figure 4. Description of patients by complete resolve of nasal obstruction related complications after one year of septoplasty For nasal blockage, symptoms were completely resolved from 18/25(72%), 26/40(65%), 11/27(41%), 8/18(44%) and 5/13(38%) of the patients in age groups 20, 21-25, 26-30, 31-35, and 36 years, respectively. For breathing trouble, symptoms were completely resolved from 16/22(73%), 25/37(68%), 7/13(54%), 4/10(4) and 6/14(43%) of the patients in age groups 20, 21-25, 26-30, 31-35, and 36 years, respectively. For sleeping trouble, symptoms were completely resolved from 19/22(86%), 24/35(69%), 18/23(78%), 14/16(88%) and 12/14(86%) of the patients in age groups 20, 21-25, 26-30, 31-35, and 36 years, respectively. For exercise problem, symptoms were completely resolved from 15/15(10), 25/31(81%), 18/22(82%), 13/13(10) and 10/12(83%) of the patients in age groups 20, 21-25, 26-30, 31-35, and 36 years, respectively. 4. Discussion The assessment of quality of life after certain surgical procedures plays an important aspect of research outcomes has received growing significance in latest years. Consequently in the present study we tried to evaluate the ultimate improve of quality of life after one year of Our assessment depend on the absence or reduction in the degree of the initial clinical complains related to nasal obstruction before This is done through the follow up of patients for one year after Of the clinical complains evaluated in the present study was nasal congestion. Nasal congestion completely eliminated from 61.5% of the patients and comforted to lower degrees in the majority of them. Moreover, nasal
86 Abdullah Alotaibi: Quality of Life in Patients with Nasal Obstruction after One Year of Septoplasty blockage was completely eliminated in 70.7% of the patients with significant lowering in the severity of all cases. However, similar outcomes were previously reported. One study found that septoplasty was successful relieved nasal obstruction in 70.5% of patients. Rhinitis, including allergy, congestion, postnasal drip and rhinorrhea did not significantly disturb the success in relieving nasal obstruction [11]. This positive association between septoplasty and relief of nasal congestion and/or obstruction was supported by several studies [12, 13]. However, some studies have another point of view, that Long-term results after septoplasty are inadequate. Apart from a recurrence of deviation, there are various reasons for this: false preoperative analysis, complete straightening of the septum, and a distressed nasal cycle. Preoperative functional diagnostics with a combination of rhinoresistometry, acoustic rhinometry, and long-term rhinoflowmetry are essential for distinguishing between "physiological" and "pathological" septal deviations and spotting other causes for nasal obstruction. The surgical method of septoplasty comprises methodology, mobilization, resection, reposition, and lastly rebuilding of all three layers. The goal of the operation should not be complete straightening of the nasal septum. The space between the septum and turbinates is of utmost importance [14]. However, the majority of studies evaluating the objective advantage of septoplasty did not follow the recommendations of the committee report on the standardization of rhinomanometry. Only three prospective controlled trials, with pooled data from 141 cases, were identified for meta-analysis, which concluded that it can be drawn regarding objective improvement in airway function next nasal septal surgery are limited. More long-term studies, adhering to standardized procedures, are required to deliver more substantial results [15]. Furthermore, in the present study, breathing troubles, sleeping troubles and exercise problems have disappeared from around 7, 97.2% and 87% of the patients respectively. Several studies reported that septoplasty could be recommended for patients with breathing troubles to ensure better nasal breathing outcomes. This was found to be significantly improve the nasal breathing quality of life [16-18]. For particular evaluation of septoplasty consequence measurement nasal obstruction symptom score (NOSE) and sino-nasal outcome test (SNOT22) forms offer exceedingly predictive values [19-21]. Subjective evaluation of upper airway is usually done with rhinomanometry and acoustic rhinometry, which are used by investigators as well. It was found that septoplasty has a positive outcome on pulmonary functions, and this can be an important hint for the association between lung disorders and nasal obstruction [22]. In conclusion: Septoplasty leads to a highly significant improvement in quality of life and relief of symptoms. Septoplasty is a very effective and satisfactory treatment for nasal congestion, nasal blockage, breathing trouble, breathing trouble, sleeping trouble and exercise problems caused by nasal septal deviation. Ultimate benefit can be assessed after one year of Author would like to thank doctors Bassam Ahmed Almutlaq, Fawaz sulaiman alshammari, Abdulrahman Saeed Alharbi, Abdullah Ahmed Alkhalaf, for their help in sample collection and Prof. Hussain Gadelkarim Ahmed for manuscript revision. REFERENCES [1] Resende L, Carmo CD, Mocellin L, Pasinato R, Mocellin M. Disease-specific quality of life after septoplasty and bilateral inferior turbinate outfracture in patients with nasal obstruction. Braz J Otorhinolaryngol. 2017 Jul 29. pii: S1808-8694(17)30115-5. doi: 10.1016/j.bjorl.2017.07.001. [2] Bezerra TF, Stewart MG, Fornazieri MA, et al. Quality of life assessment septoplasty in patients with nasal obstruction. Braz J Otorhinolaryngol. 2012 Jun; 78(3): 57-62. [3] Jessen M, Malm L. Definition, prevalence and development of nasal obstruction. Allergy. 1997; 52(40 Suppl): 3-6. [4] Stallman JS, Lobo JN, Som PM. The incidence of concha bullosa and its relationship to nasal septal deviation and paranasal sinus disease. AJNR Am J Neuroradiol. 2004; 25(9): 1613 1618. [5] Smith KD, Edwards PC, Saini TS, Norton NS. The prevalence of concha bullosa and nasal septal deviation and their relationship to maxillary sinusitis by volumetric tomography. Int J Dent 2010, 2010. [6] Bugten V, Nilsen AH, Thorstensen WM, Moxness MHS, Amundsen MF, Nordgård S. Quality of life and symptoms before and after nasal septoplasty compared with healthy individuals. BMC Ear, Nose, and Throat Disorders. 2016; 16: 13. doi:10.1186/s12901-016-0031-7. [7] Baumann I. Septoplasty update. Laryngorhinootologie. 2010 Jun; 89(6):373-84. doi: 10.1055/s-0030-1252057. [8] Kayahan B, Ozer S, Suslu AE, Ogretmenoglu O, Onerci M. The comparison of the quality of life and intranasal edema between the patients with or without nasal packing after Eur Arch Otorhinolaryngol. 2017 Mar; 274(3): 1551-1555. doi: 10.1007/s00405-016-4403-9. [9] Schwab JA, Pirsig W. Complications of septal surgery. Facial Plast Surg. 1997 Jan; 13(1):3-14. [10] Carr AJ, Gibson B, Robinson PG. Is quality of life determined by expectations or experience? BMJ. 2001; 322:1240 1243. [11] Samad I, Stevens HE, Maloney A. The efficacy of nasal septal surgery. J Otolaryngol. 1992 Apr; 21(2): 88-91. [12] Mengi E, Cukurova I, Yalçın Y, Yiğitbaşı OG, Karaman Y. Evaluation of operation success in patients with nasal septal deviation with quality of life scale and objective methods. Kulak Burun Bogaz Ihtis Derg. 2011 Jul-Aug; 21(4): 184-91. doi: 10.5606/kbbihtisas.2011.024. [13] Posnick JC, Fantuzzo JJ, Troost T. Simultaneous intranasal procedures to improve chronic obstructive nasal breathing in patients undergoing maxillary (le fort I) osteotomy. J Oral Maxillofac Surg. 2007 Nov; 65(11): 2273-81.
Research in Otolaryngology 2017, 6(6): 81-87 87 [14] Mlynski G. Surgery of the nasal septum. Facial Plast Surg. 2006 Nov; 22(4): 223-9. [15] Singh A, Patel N, Kenyon G, Donaldson G. Is there objective evidence that septal surgery improves nasal airflow? J Laryngol Otol. 2006 Nov; 120(11): 916-20. [16] Younes A, Elzayat S. The role of septoplasty in the management of nasal septum fracture: a randomized quality of life study. Int J Oral Maxillofac Surg. 2016 Nov; 45(11): 1430-1434. doi: 10.1016/j.ijom.2016.06.001. [17] Chambers KJ, Horstkotte KA, Shanley K, Lindsay RW. Evaluation of Improvement in Nasal Obstruction Following Nasal Valve Correction in Patients with a History of Failed Septoplasty. JAMA Facial Plast Surg. 2015 Sep-Oct; 17(5): 347-50. doi: 10.1001/jamafacial.2015.0978. [18] Fuller JC, Levesque PA, Lindsay RW. Assessment of the EuroQol 5-Dimension Questionnaire for Detection of Clinically Significant Global Health-Related Quality-of-Life Improvement Following Functional Septorhinoplasty. JAMA Facial Plast Surg. 2017 Mar 1; 19(2): 95-100. doi: 10.1001/jamafacial.2016.1410. [19] Stewart MG, Smith TL, Weaver EM, Witsell DL, Yueh B, Hannley MT, et al. Outcomes after nasal septoplasty: results from the nasal obstruction septoplasty effectiveness (NOSE) study. Otolaryngol Head Neck Surg. 2004 Mar; 130(3): 283 90. [20] Hopkins C, Gillett S, Slack R, Lund VJ, Browne JP. Psychometric validity of the 22-item sinonasal outcome test. Clin Otolaryngol. 2009 Oct; 34(5): 447 54. [21] Buckland JR, Thomas S, Harries PG. Can the sino-nasal outcome test (SNOT-22) be used as a reliable outcome measure for successful septal surgery? Clin Otolaryngol Allied Sci. 2003 Feb; 28(1): 43 7. [22] Tuzuner A, Bilgin G, Demirci S, Yuce GD, Acikgoz C, Samim EE. Improvement of Pulmonary Functions Following Septoplasty: How Are Lower Airways Affected? Clinical and Experimental Otorhinolaryngology. 2016; 9(1): 51-55. doi:10.21053/ceo.2016.9.1.51.